CANCER PAIN MANAGEMENT By: Corinne Manetto, Ph.D., Denice Economou RN, MN, AOCN, Barbara Hastie MA The following article is intended to serve as an overview of cancer pain management. It is by no means an exhaustive review and the reader is referred to the references at the end for additional information. Specific facts and figures are given throughout the text in order to educate the reader. The underlying goal of this paper is to assist patients and care-givers to advocate for more effective pain management. Pain should not be viewed as an untreatable consequence of cancer. Rather, it should be noted that 90% of all cancer pain can be very easily relieved. The additional 10% can be managed with the available technologies. The benefits of managing pain that can so easily interfere with one's mood, ability to sleep, eat, interact with others, and enjoy activities, will lead to a significant elevation in the quality of life for patients and their families.
The Magnitude of the Problem Cancer patients and their families must contend with significant changes in many aspects of their lives. These include alterations in social, employment, financial, and physical and psychological functioning. Compounding these life changes is the unfortunate reality that as many as 30% to 45% of cancer patients at the time of diagnosis, or shortly thereafter, may experience moderate to severe pain (Daut and Cleeland, 1982). This statistic rises to 90% for those patients with advanced disease ( Bonica, 1990). Moderate to severe pain is experienced by 40% to 50% of patients, while 25% to 30% describe it as severe. It has been reported that as many as 1.1 million Americans annually may experience cancer-related pain (worldwide studies suggest over 9 million individuals may be similarly affected). Pain has been defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" ( International Association for the Study of Pain, 1979). The causes of pain in cancer patients are often multiple. Patients may experience pain that directly results from their cancers, procedures used to evaluate and treat them, and/or pre-existing conditions (e.g., diabetes, arthritis). The most common reason for pain is tumor pressing on nerves, bone and/or various organs. The Assessment of Pain The successful management of pain requires a thorough assessment and careful monitoring of pain and related symptoms. Inadequate assessment of pain is the primary barrier to pain alleviation (Levy, 1996). To address this, the following recommendations have been made for the assessment of pain by the Agency for Health Care Policy and Research (AHCPR, Management of Cancer Pain, 1994).* The initial evaluation of pain should include the following: 1. Detailed history, including an assessment of the pain intensity and character. The mnemonic "ABCDE", developed by the AHCPR, can be incorporated to insure adequate assessment, and is as follows:
*The Agency for Health Care Policy and Research (AHCPR) commissioned The Clinical Practice Guideline for the Management of Cancer Pain. The guideline for practitioners establishes standards of care in cancer pain management. The guideline for patients (in English and Spanish, pediatric and adult versions) explains the principles of cancer pain management to increase consumer knowledge and health care options. These guidelines are available free of charge to clinicians, patients, and family members by calling National Cancer Institute's toll-free number at 1-800-4CANCER. In order to assess pain and the efficacy of pain interventions, it is helpful for patients, caregivers and clinicians to talk about the pain in a similar language. The three most commonly used instruments include:
Additional scales have been developed for the pediatric patient and those with special needs. These scales can easily be adopted to assess other factors that are both causes of, and, correlates of pain (e.g., sleep disturbance, anxiety, depression, quality of life, fatigue, constipation, appetite). Pain is a Multidimensional Experience Although it is recognized that pain is a complex perceptual experience involving the patient and his or her support system, the assessment and management of pain often focuses exclusively on the physiological aspects of pain (Craig, 1994). This occurs despite the extensive literature suggesting the lack of relationship between the sensory aspects of pain and the ultimate experience of pain (Fordyce, 1988; Romano et al., 1989). The experience of pain is colored by an individualās unique physiology, psychology, sociocultural, and family background. Several studies have suggested that psychosocial factors are better predictors of pain than the extent or site of pathophysiological damage. For example, Spiegel (1985) has found that fear and meaning of the pain relate more closely to pain ratings in cancer patients than the extent or site of metastases. Flor and Turk (1993) have shown that a patientās assessment of helplessness/hopelessness correlate more closely to pain ratings than physical factors do. The prevailing model of pain emphasizes the importance of distinguishing between pain and suffering. Suffering has been defined as the emotional response of the nervous system to harm or to the threat of harm. Pain cannot be adequately managed without assessing and managing the suffering of the patient and his or her family members. Unattended suffering, which may be reported as depression, interpersonal problems, loss of role functions, and a host of other symptoms, can result in suicide preoccupation and requests for physician assisted death especially in the presence of unmanaged pain. By carefully addressing and treating pain and related suffering, the quality of life of patients and their caregivers will be greatly enhanced.
Multidisciplinary and Multidimensional Aspects of Pain Although few would argue that pain is a complex perceptual experience involving multiple determinants, the assessment and management of pain ofter focuses exclusively on the physiologic aspects of pain. This occurs despite the fact that there is an extensive literature suggesting the lack of relationship between the sensory-nociceptive aspects of pain and the ultimate experience of pain. Indeed, several studies have suggested that psychosocial factors are better predictors of pain than the extent of pathophysiologic damage. For example, Spiegel, 1985 has found that fear and meaning of pain tended to be a better predictor of the pain experience in cancer patients than the extent or site of metastases. Other researchers have shown that patients’ feelings of hopelessness and helplessness were good predictors of pain ratings, whereas physical factors were not entirely predictive of pain severity. Given the liklihood that the elderly will experience changes in cognitive status, motivational, behavioral and affective capacities, a comprehensive assessment of pain and related symptoms is required. The inability to manage symptoms that effect pain and its treatment (i.e., sleep disturbance) will severely limit success. According to current models of pain management in order to manage pain, the emotional concomitants of pain must be assessed and treated also. Given the frequency and complexity of pain in the elderly in the face of challenging psychologic variables, suffering in the cancer patient can be quite severe. On the other hand, recent studies have suggested that the elderly can benefit significantly from multidisciplinary pain management. In addition to increased efficacy and patient satisfaction, these programs have been shown also to be cost-effective (Sobel,1993).
The Consequences of Untreated Pain For many cancer patients and their families, pain is the most feared consequence of their disease. Despite the fact that 90% of all cancer pain can easily be relieved, recent studies suggest that the inadequate management of pain may occur in as many as 42% of cancer patients (Cleeland, 1994). This is particularly alarming in light of increasing evidence indicating that unmanaged pain can lead to profound adverse effects in patientsā physiological, psychological and immunological functionings. There may be, for example, pulmonary complications that result from the immobility of a post-surgical patient because of pain. Untreated pain may alter levels of catecholamines (brain chemicals) causing an alteration of pain modulation and transmission making future pain harder to treat. Unrelieved pain is often associated with depression, distress and despair. And there is recent evidence in animal models that immune function can be negatively impacted by uncontrolled pain. (Liebeskind, 1991). Barriers to Effective Pain Management While the factors leading to inappropriately treated pain are many, patient, family and community/cultural barriers can be of particular consequence (Ward, 1993). A careful assessment of patient and family variables is required to fully understand why effective pain relief has not been achieved. Individualās reactions to illness and pain include learned responses from their families and cultural contexts. If, for example, stoicism is a valued trait, in a family or cultural group, it may make it more likely that a cancer patient will not complain. Specific patient barriers include a reluctance on the part of the individual to report pain. While there are many reasons that patients do not talk about their pain, the following is the list of the most common: fear of distracting the physician from treating the underlying disease; fear that increased pain means disease progression; and concern with complaining about symptoms for fear of not being seen as a "good" patient (Ward, 1993). Additionally, patient and family fears of addiction, tolerance and side-effects to medications lead to medication underuse. Through education and assessment, patients and their caregivers can be easily reassured. Addiction and tolerance are very distinct phenomena. Addiction is characterized by misuse of a drug for psychological effects, the development of physical dependence (e.g., that withdrawal symptoms occur if the drug is then stopped), and drug craving and extraordinary drug-seeking behavior. Studies of many thousands of cancer patients illustrates that opioids, when taken for pain relief, do not cause addiction. Education is required to dispel the myth of addiction, particularly in view of the fact that many individuals have grown up in the "Just Say No" campaign against drug abuse. Below we list the myths that still exist and can discourage patients and their families of receiving the best care possible.
An alternative campaign to assist pain patients might be "Just Say Yes to Pain Control." Tolerance differs from addiction and is defined as a normal physiological response to long-term opioid use. This may require larger doses of opioids for the same level of pain relief or simply switching opioids. The most common side-effects of opioids include constipation and sedation. Other side-effects may include nausea, dry mouth and urinary retention. Unfortunately, tolerance to the constipating effects of opioids occurs rarely. However, combination of laxatives and stool softeners can easily relieve the problem. The sedating, nauseating and respiratory depressant effects of pain medications are rarely a problem when they are used appropriately. In addition, when required, effective agents can be utilized to combat side-effects. For example, stimulants can be used to reduce sedation. Additional barriers to effective pain management include problems related to health care professionals as well as problems related to the health care system. Lack of knowledge of pain management and ineffective assessment of the pain are the most common causes of inadequate pain care associated with health care practitioners. Health care system barriers include: federal regulation of controlled substances, low priority given to pain management, lack of access and availability to pain management options. Pharmacologic and Non-pharmacologic Pain Interventions There are many ways to manage pain safely and effectively. A simple and reliable method of managing cancer pain has been developed by the World Health Organization (WHO, 1990). In this system, pain is managed according to its severity. Mild pain might be well managed with acetaminophen or aspirin while moderate symptoms may require the use of opioids. Severe pain almost always necessitates the use of long-acting opioids in combination with adjuvant therapies. The five essential principles of management according to the WHO ladder include:
STEP LADDER APPROACH TO CHRONIC PAIN MANAGEMENT*
Non Pharmacologic Methods of Pain Control Non-pharmacologic methods of pain control include physical and psychological
modalities. It has been shown that for some pains the use of hot or cold as well as massage may be effective in sending a relief message to your brain. Researchers believe that the impulse to the brain that carries a message of pain may also carry the message of heat, cold or pressure. So by applying these to the skin you may block or lessen the impulse for pain to the brain. It doesn’t work for all kinds of pain but for some it can be beneficial and can be done without a prescription. You don’t know until try it. Heat or cold can be especially helpful for myofacial like pain. Heat is effective for sore muscles and cold may work better for spasm-type pain. For heat you can use a comfortably warm heating pad, a hot water bottle or a hot moist towel. Always be sure not to lie directly on a heating pad and also test the temperature carefully. Be careful not to heat over metal jewelry as it can take up the heat and cause a burn in that area. For cold use a sealed gel pack that you can purchase in the local drug store. Ice cubes can also be used but sometimes the melting can cause linens and clothing to get wet. For messaging with ice, freezing a paper cub with water in it, than tearing off the top edge of the cup, can provide an easy to handle ice cube to use. Massage or pressure techniques can provide relief as well as relaxation for some patients. Massage involves slow, circular movements over or near the area that hurts. Using massage oil or lotion can be very soothing to prevent friction. Adding scented oil can also add to the effect. Certain types of Aromatherapy have been shown to help increase your immune system as well. This can be done by using a diffuser with "essential oils" of various aromas proven to be immune-enhancing, calming or relaxing. Others may choose to have the aromas placed around their home. There are also other ways to use these "helpful scents", and most can be purchased at a low cost. Pressure techniques involve firm pressure with a hand on the skin over or near the painful site. Sometimes if the patient cannot tolerate direct touch or pressure over the painful sight applying pressure on the opposite side may have the same effect. Depending on the source and location of pain, it may be necessary to consult a physical or massage therapist to ensure safety with this technique. Yet , it can be very useful in the relief of pain and the value of "tourch therapy" has been proven in many cases Physical therapy and range-of-motion exercises may help prevent muscle atrophy and other problems related to disuse syndromes. Acupuncture and transcutaneous electric nerve stimulation (TENS) can be very effective in the treatment of nerve and muscle pain. Regardless of whether a person has pain, a medical illness, or just experiencing normal "stressors," researchers continue to demonstrate profound benefits from relaxation and stress management through a variety of techniques. There are many types of non-pharmacologic relaxation and stress management techniques, but not all forms will work for everyone although most people can receive benefit from at least one type. For instance, techniques such as imagery, hypnosis, biofeedback, and relaxed breathing increase feelings of self-control and may promote healing. Since its discovery in 1976 termed by Dr. Herbert Benson, a cardiologist from Harvard University Medical School, the Relaxation Response is the core of most all relaxation techniques. The profound effects of this simple technique continue to be demonstrated by researchers and often amaze patients with the benefits. The National Institutes of Health has revealed the Relaxation Response as a key component in aborting migraines as well as assisting in pain management and a number of other medical disorders. Guided imagery has been found to be especially useful for reducing levels of pain, anxiety, and even reduced need for pain medication following medical procedures (Sobel & Ornstein, 1996; Tusek et al, 1997). The "mechanisms of action" of guided imagery are not specifically known, but several factors may be affected. For instance, using tapes for guided imagery may increase a patient’s sense of control which may, in turn, reduce anxiety and change physiological reaction. Similarly, both imagery and music have been shown to improve mood and enhance immune function. These techniques may also provide needed distraction from distressing events or pain. Hypnosis often has a negative connotation and is often a frightening concept due to its misrepresentation on stage and in the media. Contrary to what is often believed, a person is always conscious aware and in control when they are "hypnotized." Some people may be more "hypnotizeable" than others and more suggestible. Regardless, the hypnotized person is always in control and, if willing, has the ability to use hypnosis to tap into more "unconscious" part of the mind to enhance healing, decrease aversions, or to benefit from positive suggestions. With professional hypnosis or self-hypnosis, research has demonstrated remarkable benefits. Just like other forms of stress management, there are different kinds of hypnosis and it is best to pursue this option with a trained mental health professional. Biofeedback is used as an "adjunct" to other relaxation and stress management techniques. Essentially, it is a way of monitoring one’s sympathetic nervous system, their stress response, and the positive physiological changes that can occur with relaxation. As a result, a person can learn to distinguish a "stress response" from a "relaxed" (immune-enhancing) response. Biofeedback is very useful in demonstrating the effects of negative thought, pain, distress, or unpleasant situations on the nervous system, which ultimately has dramatic effects on the body and mind as well as a whole host of negative reactions. Research has shown that when a person is trained in biofeedback, they can learn to engage the more "healthy" side of the nervous system (parasympathetic nervous system) in order to reduce anxiety, help to manage pain, improve sleep, and assist in a number of other disorders. The National Institutes of Health have published findings of relaxation and biofeedback with regard to a number of medical disorders. In sum, biofeedback provides understanding and a useful link between the mind and body. Research has shown significant effects of addressing spirituality in the course of treatment. The inclusion of spiritual counseling or pastoral support in the care of cancer patients as well as to assist with both pain and suffering. If clergy or trained pastoral staff are not available, it may still be important to address a person’s spirituality as a source of strength and support in the midst of pain and disease. For over twenty years, Dr. Herbert Benson from Harvard University School of Medicine has demonstrated the "power of prayer" in medical outcomes and patient outlook. Spirituality can be an important addition to helping a person cope. This may be an untapped resource that the person can use by him/herself or with the help of their spiritual support network, congregation, parish, or synagogue. There are many techniques and supports that may be useful in the treatment and management of cancer pain. The most important thing to remember is that pain relief is a basic human right and we make a better place for humanity when we can ease the suffering of another. Pain is not inevitable nor is suffering.
References:
Corinne Manetto, Ph.D. is currently the Co-Director of Pain Management Services and the Coordinator of Psychological Services at the Cedars-Sinai Comprehensive Cancer Center. After receiving her Bachelor's Degree from the State University of New York at Stony Brook, she went on to complete a Ph.D. in psychobiology. She had an active career in brain research studying the basic mechanisms underlying pain and other psychological states until l987 when she began preparation for a career in clinical psychology. She completed her clinical psychology training by doing an internship at the Neuropsychiatric Institute at UCLA with an emphasis in oncology. Since that time, she has worked in the area of oncology with a focus in cancer pain management. Dr. Manetto is also the Vice-Chair of the Southern California Cancer Pain Initiative, a non-profit volunteer organization, whose primary goal is to insure that no cancer patient will suffer needlessly in pain. Denice Economou RN, MN, AOCN is currently the Senior Nurse Coordinator on the Cancer Pain Management Service at the Cedars-Sinai Comprehensive Cancer Center. She has a Master’s Degree as an Oncology Clinical Nurse Specialist from the University of California, Los Angeles. She is also a board member for the Southern California Cancer Pain Initiative. Denice is currently the Nominating Chairperson on the Greater L.A. Chapter board of the Oncology Nursing Society |
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